关键词： Cardiology   Cardiovascular disease   Carotid endarterectomy   Myocardial infarction   Post-operative complications   Referral and consultation  

摘要： Objective: The aim was to determine the clinical impact of routine cardiology consultation before carotid endarterectomy (CEA) in neurologically asymptomatic patients, in terms of early and long term cardiovascular events. Methods: A single centre retrospective review of consecutive patients receiving CEA from 2007 to 2017 for asymptomatic carotid stenosis was performed. Two groups were compared: patients operated on from 2007 to 2012 received a pre-operative cardiology consultation only in selected cases (group A);from 2012 to 2017 patients received a routine pre-operative cardiology consultation (group B). In hospital death, myocardial infarction (MI), heart failure, dysrhythmias, and stroke were compared. A multiple logistic regression was performed to identify predictors of peri-operative complications. Long term overall survival and freedom from fatal cardiovascular events were compared. Results: In total, 878 CEAs were performed in group A and 1094 in group B. Patients in group B were more likely to have had a previous coronary intervention (0.5% vs. 5.1%;p < .001), and to be on dual antiplatelet (4.6% vs. 9.5%;p = .001), statin therapy (60.3% vs. 72.4%;p < .001), and a higher number of cardiac drugs (1.77 +/- 1.22 vs. 1.92 +/- 1.23;p = .01) at the time of CEA. In hospital mortality was 0.1% for both groups (p = 1.0), and there were no significant differences regarding neurological complications (0.8% vs. 0.3%;p = .20);group B had a significant reduction in overall cardiac complications (3.4% vs. 1.9%;p = .05) and MI (1.6% vs. 0.6%;p = .05). Multivariable analysis confirmed that routine cardiology consultation was an independent predictor of MI (odds [OR] ratio 0.61;p = .04) and overall reduction in cardiac complications (OR 0.28;p = .01). At five years, overall survival was similar (84.2% vs. 82.4%;p = .72), but patients in group B had a significantly lower mortality from cardiovascular events (92.0% vs. 95.8%;p = .04). Conclusion: Routine cardiology consulta

摘要： Purpose Left ventricular assist devices (LVADs) are increasingly used as bridge to transplant (BTT) or destination therapy (DT) in end-stage heart failure. Although LVAD therapy improves clinical outcomes, neurological events including ischemic and hemorrhagic cerebrovascular accidents (ICVAs & HCVAs) are still common complications. The purpose of this study was to identify the risk factors for CVAs in patients implanted with HeartWare *** Patients implanted with LVADs between 2005 and 2019 at a single site were included. ICVAs and HCVAs were assessed, and risk factors including blood pressure management and INR were *** A total of 196 patients were implanted with the HeartWare LVADs as DT or BTT between 2005 and 2019. Patients had a mean age of 51±13 years; 67.9% were male, and the mean number of support days were 291±341. The prevalence of CVAs was 13.8% for ischemic (27 of 196) and 5.1% (10 of 196) for hemorrhagic (p<0.05), with a median age of 53 and 50 respectively. The rate of ICVAs and HCVAs per patient year was 0.90 and 0.27 for the first 30 days post-implant, and dropped to 0.10 and 0.04 after 30 days. CVA’s were more prevalent prior to discharge with 56% of ICVAs and 40% of HCVAs occurring during index hospitalization. The mean INR peri-stroke for out-of-hospital ICVAs and HCVAs were 2.1 and 3.2 respectively (p<0.05). The INR time in therapeutic range was 47.2%±23 for patients who suffered an ICVA and 43.7%±21 for HCVA, compared to 51.1%±24 for non-stroke patients (p<0.05). Furthermore, the average mean arterial pressure (MAP) measured up to 90 days prior to the CVA was 79 mmhg for patients who developed ICVAs and 75 mmhg for HCVAs (p=0.37).Conclusion Both ICVAs and HCVAs are major complications for patients implanted with LVADs. The highest risk occurs during the first 30 days post-implant with most occurring during the index hospitalization. A low INR TTR was associated with risk of developing both ICVAs and HCVAs. Targeting a hig

摘要： Updated diagnostic and management algorithms Management protocol which summarizes how the module is to be used Checklists of “to-do” items in the first few hours Expanded sections for prehospital providers, nursing, and pediatrics Updated pharmacotherapy manuscript with new medications, removal of less relevant medications, and the addition of alternative medications to reflect global variability Updated/new figures and neuroimaging Clinical pearls and take-home points Detailed communication tables with sample scenarios to use when transitioning care from prehospital to emergency department (ED) and from ED to neurocritical care unit. Acute ischemic stroke (AIS) care has evolved considerably in the last few years, and the AIS manuscript has been extensively rewritten to reflect current practice guidelines from the American Heart Association regarding thrombolytic candidacy, rapid imaging to identify large vessel occlusion and salvageable tissue, especially in late window presentation of AIS for endovascular therapy suitability [2]. The use of targeted temperature management has continued to evolve in this setting, and recent changes have been incorporated into the resuscitation after cardiac arrest module. ENLS version 4.0 protocol authors Module Authors Introduction Chitra Venkatasubramanian, MBBS, MD, MSc, FNCS George A. Lopez MD, PhD, FNCS Kristine H. O’Phelan, MD, FNCS Acute non-traumatic weakness Aimee Aysenne, MD, MPH Shahana Uddin, MBBS, MD Acute ischemic stroke Archana Hinduja, MD Noah Grose, BSN, MSN, ACNP-BC Deborah S. Tran DNP, RN, CNRN, SCRN, NE-BC Aaron Raleigh, BA, EMT-P Airway, ventilation, and sedation Asma Moheet, MD, FNCS Venkatakrishna Rajajee, MBBS Stephanie Qualls, RN, BSN, CNRN Marlina E. Lovett, MD Approach to the patient with coma Aarti Sarwal, MD Sara Stern-Nezer, MD Deborah S. Tran DNP, RN, CNRN, SCRN, NE-BC Intracerebral hemorrhage Arthur M. Lam, MD, FRCPC, FNCS Vineeta Singh, MD AM Iqbal O’Meara, MD Intracranial hypertension and hernia

关键词： Metronidazole   neurotoxicity  

摘要： Related neurological adverse effects to metronidazole are rarely encountered in clinical practice despite its wide use as an antibacterial or antiparasitic agent. The neurotoxicity is not dose-dependent and is fully reversible with discontinuation of the drug. We describe a young man who was receiving metronidazole for an amoebic liver abscess and developed encephalopathy and seizures. Brain magnetic resonance imaging showed characteristic bilateral symmetrical cerebellar dentate hyperintensities.

摘要： When I became a medical doctor in the early 1980s, we established diagnoses in children with neurological disorders by obtaining a history, conducting physical and neurological examinations, performing tests of blood or cerebrospinal fluid, conducting electrophysiological studies, such as electroencephalograms and/or nerve conduction studies, and performing brain computed tomography. In the same period, magnetic resonance imaging became available, facilitating image-informed diagnoses for central nervous system disorders.[1] After the 1990s, genetic diagnoses became possible for some neurological disorders.[2] From 2010, next-generation sequencing developed and became widely used in daily medical practice.[3] Consequently, genetic diagnoses improved remarkably. Gene-affecting treatment via oligonucleotide therapeutics has been developed for spinal muscular atrophy and proven to be effective in many patients. [Extracted from the article]

关键词： Enteral feeding   Nutritional assessment   Neurological and neurosurgical early   rehabilitation   Outcome  

摘要： Background & aims: Approximately 55% of neurological and neurosurgical early rehabilitation (NNER) patients are in need of enteral nutrition, but long-term nutritional assessment of these critically ill patients is suboptimal. Therefore, this study analyzed the effect of an individual nutritional assessment on weight changes during rehabilitation and impact on complications and functional outcome. Methods: 170 NNER patients on enteral nutrition were enrolled in the study. According to the initial ward, patients were assigned to receive standardized enteral nutrition (n = 107, control group) or an individual nutritional assessment (n = 63, intervention group). Weight changes, complications, assessment of the functional outcome (Early Rehabilitation Index, Barthel Index, Early Rehabilitation Barthel Index) and the length of stay were recorded and compared between groups using non-parametric tests for non-paired samples (Mann-Whitney U test for metric data or the chi(2) test for categorical data) or paired samples (Wilcoxon test). In addition, daily energy requirement was calculated and compared with daily intake. Correlation analysis by Spearman was performed to investigate linear relationship between weight changes and the difference of administered and calculated calories in both study groups. Results: A weight loss was observed in the control group, whereas the weight of the intervention group remained stable over time. The difference between calculated and administered calories correlated with weight changes in the control group. Regarding complications during rehabilitation, control patients showed more frequently impaired diuresis. In addition, control patients were suffering longer from diarrhea than patients of the intervention group. Both groups improved in functional status to a comparable degree. Relationships between these improvements and weight changes or administered calories could not be found. Conclusions: Individual nutritional assessment had not an

关键词： Aneurysmal subarachnoid hemorrhage   Intracerebral hematoma   Predictive factors   Multivariable logistic regression   Retrospective cohort study  

摘要： Objectives: Current guidelines paid little attention to a unique severe disease about intracranial hematoma owing to aneurysm rupture. We attempted to explore the predictive factors for prognosis in these poor patient population. Patients and Methods: One hundred twenty-one aneurysmal subarachnoid hemorrhage combined with intracerebral hematoma patients discharged between 2013 and 2016 were reviewed in this retrospective study. Unfavorable outcome was defined as a modified Rankin Scale (mRS) score of 3, 4, 5, or 6 at 6 months. Multivariable logistic regression was performed to evaluate the association of unfavorable outcome with pre-operative and postoperative clinical characteristics. Results: Of 121 patients with intact follow-up data, 34 (28.10 %) had an unfavorable prognosis. The preoperative prognostic model included patients' age, respiratory rate, Hunt-Hess scale, red cell distribution width, and serum sodium at admission. The postoperative prognostic model included patients' age, respiratory rate, red cell distribution width, serum sodium, postoperative delayed cerebral ischemia, and pulmonary infection. Both preoperative and postoperative prognostic models had excellent discrimination with Area Under The Curve (AUC) of 0.864 (P < .001) and 0.898 (P < .001), respectively. Conclusion: In clinical practice, we should pay more attention to those old patients with worse admission Hunt-Hess score, presenting deep-slow respiratory and lower serum sodium. Reduction of postoperative delayed cerebral ischemia and pulmonary infection might improve outcomes after aneurysmal SAH with intracerebral hematoma.

关键词： Acinetobacter baumannii   Carbapenem resistance   Colistin resistance   Intensive care unit  

摘要： Background: Colistin and carbapenem-resistantAcinetobacter calcoaceticus-Acinetobacter baumannii complex (CCR-Acb complex) was isolated from two consecutive patients in the neurological intensive care unit (NICU). An urgent reaction to this desperate situation was required. Patients and methods: Screening cultures were taken from the other patients sharing the NICU with index patients and repeated periodically. NICU was closed for new admissions. Infection control precautions (ICP) such as hand hygiene, cohorting patients colonized with CCR-Acb complex, cohorting the staff caring for these patients, daily bathing with chlorhexidine gluconate impregnated clothes, using gowns when contacting with patients and patient care area, and sodium hypochlorite tablets for environmental cleaning were enforced. Results: Screening cultures revealed carbapenem-resistant Acb complex in 12 out of 32 patients and 8 of them were colonized with CCR-Acb complex. NICU was opened for new admissions one month later. No further new cases with CCR-Acb complex were detected by screening cultures after 6 weeks with enforcement of ICP. Moreover, the rate of nosocomial infections caused by other multi-drug resistant Gram-negative bacilli (MDR-GNB) decreased significantly when rates before and after closing the NICU were compared. Conclusion: ICP were effective not only to limit the spread of CCR-Acb complex but also decreased the incidence of other MDR-GNB infections when applied adequately. (C) 2019 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences.

关键词： Severe dengue   Unusual manifestations   Sri Lanka   Serology   Molecular epidemiology  

摘要： Background: Sri Lanka experienced its largest dengue outbreak in 2017 with more than 185,000 dengue cases including at least 250 fatalities. Objectives: Our study aimed to characterize the clinical, immunological and virological features of confirmed dengue patients in Sri Lanka during the outbreak in 2017 when unusual manifestations of severe dengue were observed. Study design: Sera from 295 patients who were admitted to Teaching Hospital Kandy, Kandy, Sri Lanka between March 2017- January 2018 were subjected to NS1 antigen, IgM and IgG ELISAs, virus isolation, conventional and real time RT-PCR and next generation sequencing. Results: Primary and secondary infections were detected in 48.5 % and 51.5 % of the study population, respectively. Two hundred twenty five DENV strains were isolated (219 DENV-2, one DENV-3, two DENV-4, two mixed infections of DENV-2 and -3 and one mixed infection of DENV-2 and -4). Unusual and severe manifestations such as encephalitis, encephalopathy, liver failure, kidney failure, myocarditis, Guillain-Barre syndrome and multi-organ failure were noted in 44 dengue patients with 11 deaths. The viraemia levels in patients with primary infection and unusual manifestations were significantly higher compared to those in patients with secondary infection. A new Glade of DENV-2 Cosmopolitan genotype strains was observed with the strains closely related to those from China, Malaysia, Indonesia, Singapore and Taiwan. Conclusions: The new Glade of DENV-2 cosmopolitan genotype observed in Sri Lanka in 2017 caused an unprecedented, severe dengue outbreak. The emergence of DENV-3 and DENV-4 in the 2017 outbreak might cause future outbreaks in Sri Lanka.